A guide to lower surgery for trans men - Gender Identity Research ...

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A guide to lower surgery for trans men - Gender Identity Research ...

A guide to lower surgery

for trans men

Transgender wellbeing and healthcare


Contents

About this publication

1 Introduction

2 How do I qualify for lower surgery?

3 What are my options?

4 Hysterectomy and bilateral salpingo-oophorectomy:

why do I need this surgery?

5 Choosing the surgeon for hysterectomy and

salpingo-oophorectomy

6 Informed consent for hysterectomy and salpingo-oophorectomy:

reproductive options

7 Hysterectomy options:

8 Will there be an impact on my sexual sensation?

9 What next? genital surgery?

10 Choosing a surgeon for genital surgery

11 Informed consent for genital reconstructive surgery

12 Option 1: metoidioplasty

13 Option 2: phalloplasty

14 Sexual behaviours and keeping safe from sexually transmitted infections

(STIs)

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About this publication

This publication provides information about the various options forlowersurgery

(including genital surgery) for trans men. The aim of such surgery is to improve the

lives of trans men, both psychologically and physically, by achieving a closer match

between their genital appearance, their sexual function, and their self identification

as men. It is a guide to what can, and what cannot, be achieved through surgery.

This information will also help sexual partners of trans men, by giving them an

understanding of the range of possible outcomes, and the impact that these may

have on their shared lives.

The information is not aimed at surgeons themselves, although it may be helpful to

those medical staff who are providing other aspects of care for trans men.

The text also provides information and advice about sexual behaviours, and

sexually transmitted diseases and how to avoid them.

This publication is written by the GIRES’ team that includes doctors and trans

people. All the team members have specialist knowledge and experience in the

transgender field. The team preparing the text, and the group involved in the

consultation process, included trans men.

Dr Richard Curtis, BSc, MB, BS, Dip BA

Professor Andrew Levy, PhD, FRCP

Dr Joyce Martin, MB, ChB, D Obst RCOG

Professor Kevan Wylie, MB, MMedSc, MD, FRCP, FRCPsych, DSM

Terry Reed, BA (Hons), MCSP, SRP, GradDipPhys

Bernard Reed, MA, MBA

Acknowledgements to the surgeons:

Mr David Ralph MBBS, BSC, FRCS, MS

Mr Nim Christopher MBBS, MPhil, FRCS

Professor Stan Monstrey MD, PhD, FCCP

Thanks to Joe Swift, Charlie Kiss, Isa Forde and Simon Croft for their helpful

comments and suggestions.

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Lower surgery for trans men

1 Introduction

Although chest reconstruction surgery is almost always undertaken by trans men, 1

many do not undergo any ‘lowersurgery at all. There is no requirement to have

any of the available surgical options; full legal recognition by way of a Gender

Recognition Certificate can be obtained without it.

The desire to have a penis, and the decision to undergo complicated surgeries, are

factors that are distinctly personal. Many trans men feel psychologically, as well as

physically, incomplete without a phallus of masculine proportions. 2 However, you

are no less of a man if you decide against having this surgery, or are unable to for

health reasons. Some may feel unable to undertake such major surgery, or may

feel it is unnecessary to do so.

The context in which such decisions must be made, are not only personal but

complex and social. In broad terms it is perfectly possible to live one’s life as a man

without a penis and to be recognised as a man, but issues such as use of men’s

locker rooms, use of urinals, and taking the kids swimming are all potentially public

matters that make for difficulties for those who have not had phalloplasty. Clearly,

and for some, more importantly, there is also an impact on intimate sexual

relationships: what effect will surgery have on erotic possibilities; starting new

relationships – how and when to you explain that you’re not the same ‘down there’;

adapting existing relationships – are you sexually attracted to men, or to women?

All these considerations may impact on your decision about whether or not to have

surgery at all, and if so, what outcome you will be hoping for.

These are sensitive and complicated matters and require a very well-informed

approach to the various options. You will need a good understanding of the

variability and uncertainty surrounding outcomes and, in the light of that

understanding, you should make a realistic appraisal of what is possible. Talking to

other trans men about their surgeries or why they have chosen not to have

surgery, are important factors in the learning and decision-making process. The

1 Trans men may have chest surgery before or at the start of the change of gender role. See

Bockting, W, Knudson, G, Goldberg, J (2006) Counseling and mental health care for transgender

adults and loved ones. International Journal of Transgenderism 9(3/4):35– 82. Available at

www.vch.ca/transhealth/resources/library/tcpdocs/guidelines-mentalhealth.pdf

2 Phallus is the generic term for either a penis or a clitoris. Male and female phalluses are made of

the same basic tissue and, in the very early stages of development, the phallus is not

differentiated into male and female. In later development, the difference is not only one of size, but

also the positioning of the urethra (the tube you urinate through). In a (typical) penis, the urethra

passes through to the tip, whereas it emerges below the clitoris.

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support of loved ones who are able to give you enough personal space to consider

your options, but who will also accompany you on your journey, is enormously

beneficial.

2 How do I qualify for genital surgery?

In the UK irreversible genital surgeries are not usually undertaken until you have

lived continuously as a man for at least 12 months and are over the age of 18. This

is in accordance with the Harry Benjamin Standards of Care. 3 “This length of time

is arbitrary and represents the understandable caution of clinicians who are

concerned that irreversible surgery may be mistakenly undergone if there has been

a shorter period of living full-time in the new role” (Guidance for GPs, other

clinicians and health professionals on the care of gender variant people). 4 Some

studies indicate that compliance with minimum eligibility requirements for genital

surgery specified by HBIGDA Standards of Care is not associated with more

favourable outcomes (Lawrence, 2001; 2003) 5, 6 Some individuals may feel ready

for surgery in a shorter time, but this is a major and irrevocable step and many do

not feel ready for two or three years.

Two referrals supporting your clinical need for genital surgery are usually required

before a surgeon will undertake it. In the UK one of these must be from a medical

doctor (a gender psychiatrist) and the other can be a psychologist, endocrinologist

or GP for instance. Once you have been referred for surgery to a UK surgeon, you

can expect to have your first operation within the 18 weeks. Waiting times abroad

however, may be much longer; in Belgium, for instance, the waiting time for

consultation is 5 – 7 months and, at the time of writing (2009) is about 24 months

after that for surgery.

3 Harry Benjamin International Gender Dysphoria Association’s The standards of care for gender identity

disorder – sixth version (2001) Symposion, Düsseldorf (World Professional Association for Transgender

Health).

4 NHS Guidance for GPs, other clinicians and health professionals on the care of gender variant

people, available at www.gires.org.uk/dohpublications.php or order from DH Publications, e-mail

dh@prolog.uk.com

5 Lawrence, A.A. (2001). Sex Reassignment Surgery Without a One-Year Real Life Experience: Still

No Regrets. Paper presented at the XVII Harry Benjamin International Gender Dysphoria

Association’ Symposium, Galveston, Texas, 31 October – November 4.

6 Lawrence, A.A. (2003) Factors Associated with Satisfaction of Regret Following Male to Female

Sex Reassignment Surgery. Archives of Sexual Behavior 32,299-315.

N.b. The subjects of Dr Lawrence’s studies were trans women, not trans men, but the principle

regarding the timing of surgery holds good for both. In trans men, however, genital surgery should

always be delayed until the maximum effect of testosterone has been reached.

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3 What are my options?

It is essential that you consider all the options available. In the box below, there is

a list of possible surgeries, but you will need to look at the detail (later in this

booklet) to be as sure as you can be that you have really understood what is on

offer. Your surgeon will help you weigh up your options, and tailor surgery to your

specific needs and circumstances. At the planning stage, an in-depth consultation

with your surgeon will help you decide what you want, and what is possible in your

case. Everyone is different, so the fact that you know someone who has

undergone a particular procedure does not necessarily mean that it would be

suitable for you.

Lower surgery options –

Hysterectomy (‘hysto’ – removal of the uterus – womb)

Salpingo-oophorectomy (removal of the fallopian tubes and ovaries)

Vaginectomy (removal of the vagina)

Metoidioplasty (creates a micro-penis by bringing the clitoris

forward)

Urethroplasty (creates a repositioned, longer urethra – tube

you urinate through. This is joined to your

existing urethra – the ‘hook-up’)

Scrotoplasty (creates a scrotum and generally includes

testicular prostheses, often at a later stage)

Phalloplasty (creates a penis)

Erectile implants (creates erectile capability)

If you have started on a course towards surgery, you may still back out at

any time. You may not feel ready now, or ever, to have surgery. You should

not feel pressured to follow any particular pathway.

4 Hysterectomy and bilateral salpingo-oophorectomy (usually combined)

Why do I need this surgery?

Many trans men will have the womb, ovaries and fallopian tubes removed,

whether or not they plan to have further genital surgeries. The reasons for this are

listed below but the usual advice is to have this surgery within about five years of

starting testosterone.

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Diagram of pre-operative anatomy

BLADDER

PUBIC BONE

CLITORIS

TR

The reasons for surgery are:

UTERUS

CERVIX

VAGINA

The risk of cancer of the uterus, ovaries or cervix is overcome (the cervix

protrudes into the top end of the vagina where the uterus opens into it); 7

Smear testing to detect cervical cancer or screening processes to detect

cancers of the uterus or ovaries need not be undertaken;

The lack of a uterus, fallopian tubes and ovaries may help you feel less

female;

Periods or breakthrough bleeding are not possible;

FALLOPIAN TUBE

AND OVARY

There is no risk of pregnancy and hence no need for contraception but,

where a vagina is still present, condoms should continue to be used to

prevent sexually transmitted infections; 8

There is no longer any conflict between the effects of oestrogen (from

the ovaries) and the testosterone you are taking;

The dosage of testosterone can be greatly reduced thus minimising the

potential for long term side effects due to prolonged high dose

testosterone use;

There may be pre-existing gynaecological problems for which the ideal

treatment may be hysterectomy and salpingo-oophorectomy; and

This paves the way for further surgery, should you wish to undertake it.

7 It is thought that the risk of cancer of the uterus and ovaries may be raised in trans men where

there has been long-term, high-dose testosterone use. Testosterone can cause cysts on the

ovaries and endometrial hyperplasia (increased cell production of the lining of the uterus). It is not

possible to define the level of risk as the study to prove this would be extremely difficult to do. If

you are diagnosed with cancer, you should be referred directly to a gynaecologist/oncologist. It is

completely inappropriate for you to be obliged to have a further psychiatric referral, or to be sent

back to a Gender Identity Clinic.

8 If you have had vaginal sex with a man without a condom, you are at risk of cervical cancer and

should have regular smear tests. See also section 15 of this publication.

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5 Choosing the surgeon for hysterectomy and salpingo-oopherectomy

In the UK, gynaecologists are the experts in performing hysterectomies. However,

there are only a few who have experience in undertaking the procedure in trans

men. It is worth asking your GP to refer you to a local gynaecologist to see if he or

she would be willing to do this, but the answer may be ‘no’. Surgeons are rarely

entirely comfortable with removing healthy tissue. If they do not understand what it

means to be a trans man they may refuse to treat you. They would be equally

unwilling to operate on those who identify as neither men nor women and who

therefore may wish to have neutral sex characteristics. You will need to be referred

by a medical doctor, and you may have to search around for a sympathetic

surgeon. However, there are surgeons willing to undertake this surgery.

The implications of having a hysterectomy need to be considered in conjunction

with your thoughts on any further genital surgery you may be planning because the

choice of technique for the hysterectomy could reduce your options for the later

surgery. So it is vital that you are aware of this and discuss it with your surgeon.

Some surgical teams may do chest reconstruction at the same time as

hysterectomy and oophorectomy, and then combine vaginectomy with phalloplasty

at a later date. In the UK a hysterectomy is usually combined with one or more

stages of phalloplasty where the service user has decided that he wishes to have

further genital surgery. Each surgical team will have its own preferred procedures

and time-tabling. Many surgical teams will require you to stop taking testosterone a

few weeks before surgery to reduce the risk of surgical complications. This does

not reverse the masculinising effects that testosterone has already induced.

6 Informed consent for hysterectomy and salpingo-oophorectomy:

reproductive options

The removal of the uterus and ovaries will make you infertile so, in some ways, it is

the most important decision about surgery that you have to make.

If you wish to store ovarian tissue before having a hysterectomy and

oophorectomy, you will need to arrange this well ahead of surgery. You may obtain

advice regarding this from your GP or from the surgeon. 9 If you are in a

relationship, you may wish to discuss this with your partner and you may wish to

have some counselling, together and/or separately. You should have access to this

treatment on an equal footing with the non-trans population and the options are

9

Hamilton, M. (2007) Gamete Storage. Good Practice Guidelines for the assessment and treatment of gender

variant conditions, Appendix 1

www.rcpsych.ac.uk/pdf/Standards%20of%20Care%20Draft%20v8%203b%20final.pdf

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essentially the same as for women undergoing chemotherapy or radiotherapy. 10

Fertility centres offering licensed treatment in the UK can be found at the website

of the Human Fertilisation and Embryology Authority (HFEA) www.hfea.gov.uk.

In addition, all the usual considerations that apply to any surgery must be

discussed – outcomes, possible risks and complications – well in advance of

surgery, so that you have time to consider the advantages and disadvantages.

Make sure that you have learned as much as possible and that you ask your

surgeon anything you are not sure about. You will need to discuss which of the

techniques outlined below suits you best (especially in terms of the options with

regard to the vagina). Although you have choices, you will also have to be guided

by the surgeon, as to which is most suitable for you.

This consultation is a two-way process. Surgeons should satisfy themselves, on

the basis of their own interview with you, that this surgery is suitable in your case.

You will be asked to sign an ‘informed consent’ form before undergoing surgery. If

possible you should see a copy of this form a few weeks before the operation so

that if it raises any queries in your mind you have time to ask the surgeon further

questions.

Once you have seriously considered the issue of having children, you may decide

to delay this surgery. There is no reason whatever why trans men should not

become pregnant and give birth prior to transition.

The father in this photo is the biological

mother of this couple’s daughter

10 De Sutter, P (2007) Reproduction and fertility issues for trans people. In R Ettner, S Monstrey, E Eyler (eds.)

Principles of Transgender Medicine and Surgery , pp209–221. Haworth Press, New York.

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In rare circumstances, where hysterectomy and oophorectomy have not taken

place, a trans man may give birth even after taking testosterone for some years.

However, before this can happen, the trans man will need to stop taking hormones

until menstruation is re-established. This takes several months. In such a case,

insemination may be by a sperm donor or male partner. Very few children have

been born in this way, and no long-term data are available, but so far no problems

have been identified in these children. However, if you wish to become pregnant

and you are on, or have been on, testosterone you should obtain medical advice

beforehand.

7 Hysterectomy (and salpingo-oophorectomy) options

There are three methods of performing a hysterectomy. Each one removes the

uterus including the cervix, ovaries and fallopian tubes; usually the vagina is closed

at the top but remains open at the lower end.

Abdominal hysterectomy

This is the commonest way to perform hysterectomies on non-trans people. It is a

well-established procedure and any competent gynaecologist is well trained to do

it. It takes about one hour and involves a hospital stay of four days. Restricted

activity is recommended for up to 6 weeks.

The most important implication of this method is the six inch transverse scar across

the lower abdomen.

The external scar affects –

the ability to do an abdominal phalloplasty (i.e. using the abdomen as the

donor site for constructing the new phallus; and

the recovery time after the operation; this will be slightly longer; and

it is also more painful than other procedures.

Vaginal hysterectomy

The internal organs are removed through the vagina. There is no external scar but

there needs to be a degree of vaginal wall laxity (looseness), such as typically

occurs after childbearing. The surgeon needs to be able to reach the uterus via the

vagina. In some cases the surgeon can use a laparoscope (key hole surgery), to

assist the procedure, especially in the removal of the ovaries. It takes about an

hour to do and involves a hospital stay of three days.

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It has a slightly quicker recovery time (by a few days) because there is no

abdominal scar and abdominal phalloplasty is possible.

Laparoscopic hysterectomy

This ‘key-hole’ surgery involves the insertion of a camera and other instruments

through four very small holes in the abdomen. This is likely to be the first stage of

your lower surgery; it may include the first stage of lengthening the urethra.

Key-hole surgery is becoming more common but it is still quite specialised and

there are not many surgeons trained in this technique. It takes one and a half

hours to do this operation and involves a hospital stay of three days.

The main advantage is the absence of an abdominal scar and thus

reduced recovery time and, as above, it preserves the option of an

abdominal phalloplasty at a later date.

The vaginal wall in those who have been on testosterone for some time

becomes thin and is an unsuitable site for incisions. Approaching via the

abdomen has the advantage of avoiding making an incision in the vaginal

wall. 11

As mentioned above, the suitability of the individual to undergo the above options

can only be determined by the surgeon after a consultation and examination. So

the choice will have to be made by the surgeon and service user together, taking

account of the service user’s wishes and future intentions with regard to surgery.

Timing of procedures for hysterectomy and salpingo-oophorectomy

Operation

Abdominal

Operation time Hospital stay Recovery

one hour

four days six weeks

Vaginal

Laparoscopic

one hour

one and ½ hours

three days

three days

five + weeks

three to four weeks

Recovery times throughout this publication are given as minimum periods. Some

people take much longer than the stated time. Some surgical teams perform chest

reconstruction at the same time in which case recovery will probably take longer. A

11 O’Hanlan, K, Dibble, SL, Young-Spint, M.(2007) Less invasive hysterectomy okay for

transsexuals (sic) Obstetrics and Gynecology, 110:1096–1101. Scientific American Inc.

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lot depends on how well you are when going into surgery. You should lead a

healthy lifestyle, eat sensibly, take regular exercise, drink only modest amounts of

alcohol and do not smoke. This will all help to lower the risks associated with

surgery. In view of the fact that most trans men are youngish, fit and healthy with

no pre-existing gynaecological illness, the risk of complications is, theoretically,

small.

Risks associated with hysterectomy with salpingo-oophorectomy

The most serious risks are:

significant bleeding;

damage to the bowel and/or bladder and/or urethra;

pulmonary embolus;

deep vein thrombosis;

anaesthetic problems;

wound breakdown;

laparotomy (having to open up the abdomen); and

anaesthetic problems.

Minor complications include:

minor bleeding;

infection;

cervical stump problems (the tissue remaining where the cervix had

been at the top of the vagina); and

minor anaesthetic problems.

Removal of the vagina

Removal, or closing, of the vagina is not always the chosen option of trans men but

is typically done as part of a phalloplasty. If you are planning to have phalloplasty

later, you may need to retain the vagina until that surgery is done because the

lining of the vagina (mucosa) may be used to extend the urethra (the tube you

urinate through). The female urethra is short, so any extension of the phallus,

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either as part of a metoidioplasty or the larger phalloplasty, will require the urethra

to be extended to reach the end of the phallus. Not all trans men choose to have

the urethral extension. If you don’t have it, it will not be possible to urinate standing

up, and this is an important consideration for some trans men.

Some trans men prefer to retain the vagina as it may still be utilised during sex. If

you are having vaginal intercourse, your partner should use a condom to protect

you against sexually transmitted diseases (see section 14 below).

There are several ways to remove the vaginal opening in order to create a more

male appearing genital area.

colpectomy (a full vaginectomy – removal of the vagina) is a risky procedure

with a high, serious complication rate. The risk of haemorrhage, damage to

the bladder and rectum are significant even with an experienced surgeon.

The vaginal mucosa (lining of the vagina) is removed and the deep pelvic

muscles are sewn together. Again, prior to having this procedure,

consideration of the implications for future surgery should be discussed.

colpoplasty (vaginoplasty) is a newer procedure that involves closure of the

external opening of the vagina whilst opening the internal (cervical) end into

the abdominal cavity. The operation is less risky than a vaginectomy but still

preserves the vaginal mucosa. Vaginal cancer is therefore still possible. If

such a cancer were to develop it would therefore go unnoticed and be

difficult to get at. The risk of developing vaginal cancer is slight: one in a

million.

colpoclesis involves ablation (complete removal) of the vaginal mucosa and

fusion of the muscular walls of the vagina. It is well tolerated with a low

complication rate. Additionally since there is no vaginal mucosa, there is no

risk of vaginal cancer.

8 Will there be an impact on my sexual sensation?

During orgasm, the muscles of the uterus and the vagina contract (see diagram on

page 41), so removal of the uterus will limit the spread of orgasm, and removal or

closure of the vagina will restrict it further. The vagina and the nerves around it

provide some erogenous (sexual) sensation so this will also be lost. However, the

clitoris should be unaffected and you should have no difficulty in reaching orgasm.

If you are on testosterone, the clitoris will enlarge and your experience of orgasm is

likely to intensify which more than compensates for any diminished area of

stimulation.

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9 What next? genital surgery?

The main things to consider when deciding upon genital surgery – in no particular

order – are:

aesthetic appearance – do you want a penis that falls within the typical

(extremely variable) male range or will you settle for a micro-penis (less than

two inches)?

urinary function – do you want to urinate standing up or sitting down?

sexual function – do you want to have penetrative sex with your penis?

sexual function – is the site of sexual sensation important to you?

appearance – are you happy to have visible scars?

time – how many operations are you prepared to have?

risk factors – what level of risk are you willing to accept?

restrictions – do you have any health-related restrictions on your options?

financial – if you are funding the surgery yourself, what can you afford to do?

10 Choosing a surgeon for genital surgery

There is no substitute for talking things through with a surgeon, face-to-face. This

will help you to make up your mind about whether or not this is a surgeon with

whom you feel comfortable, and who can provide a suitable solution for you. Do

not be afraid to ask for a second opinion if you feel unsure about the first. As this

kind of highly specialised surgery is rarely undertaken, there is less choice of

surgeon with the necessary experience. Unless you can afford to pay for surgery

yourself, the matter of funding may be another obstacle to overcome and it may

limit your choices. You may consider looking abroad for a surgeon. The NHS may

fund this surgery, even overseas, if the quality of treatment and the cost are

comparable or better than that available in the UK. If you are funding yourself,

especially if this is abroad, because in addition to the costs associated with:

surgeons; anaesthetist; hospital; preliminary tests etc., there will be high travel

expenses on several occasions for appointments with a local psychiatrist and with

the surgeon.

Your meeting with the surgeon should occur some time before the actual surgery,

that is, not on the day or the day before. You may be required to undergo an

intimate examination. Although you may not be happy about this, it is necessary,

as it is extremely important that the surgeon does not find some unexpected

difficulties that affect what can be done. You may not be able to meet with your

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surgeon if you have chosen surgery outside Europe, so you will need to make sure

that the techniques offered are appropriate for you. If possible you should organise

post surgical care in the UK, just in case there are any complications. Emergency

care for major complications such as haemorrhaging would be available on the

NHS, but ‘corrections’ would not be.

Seeing the surgeon well before surgery gives you time to consider alternatives,

and to think about the opinion of the surgeon regarding likely outcomes in light of

the examination undertaken and your personal health history. This particular field

has no ‘standard’ operation. Every surgeon performs these operations slightly

differently. Some of the differences are extremely significant, especially in regard to

the preservation of sexual sensation and overall aesthetic result (that is, how it

looks). The more complex the proposed surgery, the greater is the risk of

complications.

11 Informed consent for genital reconstruction surgery

It is important to be realistic about outcomes

Both you and your surgeon will need to be sure that you are in a position to give

properly informed consent before surgery is undertaken. The surgeon should

explain the operative technique used; the likely beneficial result in terms of

appearance and function (including sexual function and erotic sensation).

Surgeons should be able to show you example pictures of their work and/or refer

you to previous patients for a ‘reference’. If such discussion is not forthcoming you

may wish to seek an alternative surgeon.

You must also be made aware of any possible complications, and surgical risks.

These will vary depending on the kind of surgery that you have chosen.

Complications may arise, no matter how competent the surgeon. Even the more

straightforward surgeries may require follow-up corrections, and some options

require a series of surgeries. You and the surgeon will have to agree an

acceptable balance between the risks and the expected benefits.

When you are confident that you have been as thorough as you can be in doing

your research, and have discussed everything with your surgeon, and the day

comes for surgery, you will be asked to read and sign an appropriate ‘informed

consent’ form stating that you understand what is going to happen and the likely

consequences of it. You and your surgeon share responsibility for making sure that

you have this understanding.

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You should also be made aware of the length of time that you will need to

convalesce, any specific post-operative care, and instructions about how and when

you might ‘test drive’ the new equipment!

Depending on the complexity of the surgery planned, you may well be looking at a

series of surgeries over time. As far as possible, you should think ahead about how

to manage family and work commitments.

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12 Option 1: metoidioplasty

“I haven’t made my mind up about phalloplasty. For the moment

I am planning to have metoidioplasty done after I have finished

my degree and before my first job so that I am not under

pressure time-wise. I have been on testosterone for three years

now and my clitoral enlargement is quite good. The more major

surgery involved with phallo is a bit scary, because of the extra

risk and the scarring to the arm (and I wouldn’t want any other

donor site used). Plus my sex life is good, and I just don’t want

to rock the boat! I also feel that having this done now, doesn’t

shut the door on having phalloplasty later, and I believe the

surgery takes less time than when a phallo is done from

scratch”. (anon).

The genital organs in both men and women develop from the same structures at

the embryonic stage (right at the beginning of your mother’s pregnancy), so the

clitoris is like a very small penis; it has similar erectile capacity. Under the influence

of testosterone, the clitoris enlarges. In order to take advantage of this enlargement

and ensure that the clitoris has reached its maximum size, it is recommended that

you have been taking testosterone for many months; some centres advocate two

years. The size varies from individual to individual but always remains smaller

than the male phallus, reaching a final size of, on average, four centimetres when

erect; you can’t urinate through it. This procedure is most suited to those who have

developed a large clitoris.

Metoidioplasty (spelt in a variety of ways but all referring to the same procedure) is

a means of exposing the hidden part of the clitoris to make it more visible and thus

appear longer (see ‘clitoral release’ below). The resulting structure is referred to as

a micro-penis or micro-phallus. The technique has been available since the 1970s.

Metoidioplasty can include various options to enhance the functionality or aesthetic

appearance of the micro-penis. There are several techniques, all of which start with

‘clitoral release’:

Clitoral release and pubic liposuction option;

Clitoral release and bulking (increasing girth of the micro-penis);

Clitoral release and scrotoplasty (formation of a scrotum, with or without

prostheses, i.e. implants); or

Clitoral release and urethroplasty (lengthening of the urethra).

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Clitoral release

The simplest operation involves detaching the clitoris from the pubic bone to which

it is attached by a ligament (this bone forms the front of the pelvis. It can be felt just

above the clitoris). The under-surface of the clitoris is then separated from the

tissues holding it down. This allows the clitoris to be moved forward and to become

more prominent, creating the appearance of a circumcised glans (the end of the

male penis). It is important to continue stretching the micro-penis to maintain its

length otherwise the ligament may reattach and the micro-penis will shrink back.

You should get advice from your surgeon about this.

18

It is possible to do this under local anaesthetic.

TR

Clitoral release with pubic liposuction option

The clitoris appears lengthened. There

are few figures available as to the

average size. The most often quoted is

four to ten centimetres. The results will

be more visible in slim individuals.

At the same time as the clitoral release, some of the fat over the pubic bone

can be removed using liposuction, and the skin pulled upwards. This makes

the micro-penis appear longer and more masculine, as men tend to have less

fat in the pubic area compared to women. Depending on the surgeon’s

technique this may leave a small scar in the pubic hair area.

Clitoral release and bulking option

If desired, the girth of the micro-penis can be increased by using the labia

minora (the inner lips around the entrance to the vagina) to bulk up the micropenis.

There is also a variant of this called the Centurion procedure. This was

developed in 2002 by a US surgeon and involves dissecting ligaments inside

the labia majora (the outside, visible lips on either side of the micro-penis)

bringing them together along its shaft to add bulk. This creates natural hollows

in the labia which can be used for testicular implants (see below for implants).

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


Clitoral release and scrotoplasty option

It is entirely possible to stop after the above options. It is more common

however to wish to create a scrotum with testicular implants. Different surgical

teams have different approaches to creating the scrotal sac but all will use the

skin of the labia majora that is expanded in one of the following ways.

Silicone implants are inserted without prior expansion of the ‘scrotal’ skin.

This is generally done as a separate procedure some months after the initial

metoidioplasty but can also be done as part of the same operation.

This option stretches the labial skin and is uncomfortable for a few days and

more uncomfortable than the option below.

The new scrotal skin is expanded gradually to accommodate the silicon

implants at a later date.

Typically at the same time as the clitoral release,

the labia majora (outer lips) are descended from

their natural position and fitted with tissue

expanders. These are composed of small bags

which have ports for the infusion of saline solution.

The patient fills the bags every seven to ten days

with five mls of fluid. Gradually the labial tissue is

stretched to a degree depending upon physical

limitation and also the appearance you are aiming

to achieve. At a later date the bags of saline are

replaced with silicone testicular implants to create

the look and feel of a scrotum.

Clitoral release

and

scrotoplasty

This is usually done several months later, under local anaesthetic. The delay gives

time for the area to heal well, making it less likely that the implants will push their

way out. This can occur but it is rare. Depending on the surgeon, the placement of

the implants will influence whether the ‘testicles’ hang between the legs or slightly

further forward.

Under the influence of gravity the scrotum will descend naturally. The two sides of

the scrotum may either be left as two structures or can be joined in the middle. If

the trans man’s thighs are on the bulky or fat side there may not be much room to

accommodate anything but a small scrotum.

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TR

19


Clitoral release

creating micropenis

Scrotoplasty

with silicone

implants in

place

In typical males the testicles are slightly

different sizes and one hangs lower than

the other.

For a slightly different approach to creating the scrotum, please see page 35.

Clitoral release and urethroplasty (lengthening of the urethra)

In order to facilitate standing to pass urine, the urethra can be lengthened. It can

be brought to the tip of the micro-penis (as in the picture above). The ability to void

while standing is not guaranteed as the size of the micro-penis may not be

sufficient to be able to clear the trousers. In the best case scenario urinating

through the flies may be possible but it may be necessary to pull down the trousers

to urinate, particularly when using a urinal. The urethral extension option is the

most prone to complications. To maximise the chance of healing a catheter is

inserted at the time of the operation, and is left in place for 2 weeks (a catheter is a

thin rubber tube that keeps the new urethra open, and carries the urine from the

bladder and out through the micro-penis).

The risk of urethral problems is high. The most troublesome issues are:

20

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urinary tract infections;

The decision regarding obliteration of the

vaginal cavity should be considered if a

scrotum is being created as once the

scrotum is descended and has achieved

its full size access to the area will be

reduced especially if the two sides of the

scrotum are joined.

HYSTERECTOMY + VAGINAL

COLPOCLESIS

CLITORAL RELEASE AND

URETHRAL EXTENSION

SCROTOPLASTY + IMPLANTS TR

fistulae – small openings where joins have to be made in the urethra,

especially where the new tissue joins with the original urethra. These

openings allow leakages of urine along the length of the urethra;

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


narrowing (stenosis) of the urethra causing difficulty urinating;

poor stream causing the urine to spray in any direction;

leaking of urine after you have finished urinating.

“After urinating and pulling my pants and trousers up, just as I was

standing and washing my hands, a dribble of urine would run down my

legs wetting my clothes. It wasn’t a huge amount but it was

uncomfortable and could have been embarrassing. My urologist

explained that I probably had a diverticulum (small bulge creating a

sac in the urethra) and that I could empty the urine collected in it, by

squeezing the scrotum and forcing the urine out. Problem solved. I

wish he had told me about this first” (anon).

The urethra can be made from several tissues. The commonest being the vaginal

mucosa (inner lining of the vagina), buccal (mouth) mucosa and the labia minora

(inner lips around the opening of the vagina). Some surgeons advise closing the

vagina if vaginal mucosa is used for the urethroplasty. Operation and recovery

times will vary depending on the complexity of the operation. Metoidioplasty with

urethral extension will be at the upper end of the timing suggested in the table

below.

Operation

Metoidioplasty

Operation time Hospital stay Recovery time

three to five hours

Advantages compared to phalloplasty:

three to four days

less risk of complications during and after surgery;

two to four weeks

one or two stage procedure (in the UK, phalloplasty can take five or

more procedures although elsewhere phalloplasty may be done in two

stages);

penis is natural looking (outcomes for phalloplasty, in terms of

appearance, may be quite variable);

cheaper;

less time recuperating and off work;

no scarring.

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Disadvantages compared to phalloplasty:

the penis is very small;

penetrative sex is extremely unlikely.

Risks:

some loss of sexual sensation;

hypersensitivity;

tissue necrosis (some tissue dies away) – this is rare;

infections;

bleeding;

stenosis (narrowing) of the urethra;

fistula (an opening of the lengthened urethra, usually where a join has

been made);

length shorter than anticipated;

vaginal opening narrowed (this may be temporary or permanent).

What about sexual sensation now?

As mentioned above, if you have had a metoidioplasty you will not be able to

achieve penetration (unless you use some other form of erectile aid).

Sexual sensation is preserved in the micro-penis so you will have erections as

normal and there should be no difficulty in reaching orgasm. There will be a slight

limitation in the spread of the sensation of orgasm if you have had a hysterectomy.

Contractions during orgasm that would usually be felt in the vagina and the uterus

will obviously be lost once these organs are removed.

Many women experience heightened sensation when the ‘G’ spot is stimulated;

this is on the front wall of the vagina, a little way above its opening on the pelvic

floor. The cervix is also particularly sensitive in some women and may be

stimulated by the penis during vaginal intercourse (see diagram page 41).

These sexual sensations in and around the vagina will more-or-less disappear if

the vagina is removed altogether. If the vaginal walls remain, however, there may

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


well be some residual sensation, especially in the vicinity of the G spot even

though this cannot any longer be directly stimulated.

Some people experience sexual sensation from the vagina during anal penetration.

If your sexual activity includes being penetrated via the anus, the removal of your

vagina will limit the possibility of this sensation but, as above, if the walls of the

vagina are still present, there may be some sexual sensation in that area.

Diagram to show the areas of sexual response following metoidioplasty with

vaginal colpoclesis

The enlarged clitoris will still be available for

direct stimulation

The tissue surrounding the vagina (shown in red)

including some of the nerve endings in the vicinity

of the G spot (see page 38), may still provide

some of the wider sensation associated with

female orgasm.

If penetration during intercourse is important to you (and to your partner) you may

need to go for option 2, the phalloplasty. However, you will need to balance this

against the small risk of losing some sexual sensation, the greater risk of

complications, and the necessity of having to undergo more surgical procedures.

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13 Option 2: Phalloplasty

“I’m still in the middle of my surgeries but I want it all done. Every

morning, in the few seconds before I am fully awake, I expect my

body to look completely male – and then I realise as I get

showered that it doesn’t yet. That’s difficult” (James, as told to

Sally Raikes, “Scotland on Sunday” on 26th August, 2006.)

In the UK trans men undergoing phalloplasty so far, have been between the ages

of 22 and 54 (average age 35). Even if you have already had a metoidioplasty, all

the matters raised in the introduction will still be relevant if you later decide to have

a phalloplasty. So, just to recap, you will need to have further discussions with

significant others: family members – especially your partner, other trans men and

your surgeon. You may also wish to have some (further) counselling. Undergoing

phalloplasty is a big step and your preparation needs to be extensive. You need to

be really sure about what you want as well as realistic about what can be achieved.

Convincing appearance and function are not always achieved so it is important that

you understand, beforehand, that results are variable and may be disappointing.

If you have not had genital surgery so far, you will need two referrals, one of which

is from a doctor who is a gender specialist and has knowledge of your trans

history. If, however, you are seeking phalloplasty as part of an ongoing process of

genital surgery with the same surgical team, you should not need further referrals.

If you have changed surgeons, the new surgeon might insist on a letter of referral.

It is not absolutely necessary to undergo hysterectomy or vaginectomy before or

during a phalloplasty procedure although most surgeons insist upon this. If that is

the case with your surgeon and you haven’t yet had any surgery, you will need to

have a hysterectomy, oophorectomy and possibly a vaginectomy (see section 7

above). Some surgeons will perform these at the same time as the phalloplasty,

but most prefer to take it a stage at a time. However, vaginectomy must be done

simultaneously if your surgeon is planning to use vaginal mucosa (lining of the

vagina) to create the urethra.

Phalloplasty itself involves several procedures that, in the UK, are done in a series

of operations. However, some surgical teams outside the UK do fewer operations

because they do several procedures in one operation (this does not include placing

the testicular implants – see page 18, and erectile implants – see pages 28 and

29). If you have had metoidioplasty then your micro-penis will be incorporated in

the new phallus.

Phalloplasty is complex and costly so obtaining funding whether via the NHS, or by

raising money to pay for private treatment, may be difficult.

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


There will be important choices to be made about intended outcomes. Your wishes

may have to be adjusted in light of the view of your surgeon about what is possible,

or likely to be achievable, in your case. Everyone’s anatomy is slightly different,

and your surgeon will take this into account.

Your penis will need to be created from your own tissue, as a graft, taken from a

donor site. Some surgeons prefer one donor site rather than another – forearm

rather than abdominal flap – for instance. The donor tissue is rolled into a basic

penis shape and may be positioned slightly differently, depending on:

whether the clitoris is to be buried under the penis or scrotum (if no

metoidioplasty has taken place) or left visible and accessible between the

testes;

whether or not metoidioplasty has already been carried out; if it has, then the

micro-penis will be incorporated into the penis by wrapping the donor tissue

around it; and

where the graft is taken from – an abdominal flap allows little choice of exact

position, whereas the forearm flap is ‘free’ and positioning is a little more

flexible.

You will also have to consider the various refinements that can be made on your

phallus. Do you want a phallus that looks good but is not functional? Is it important

to you to be able to urinate standing up? Are you hoping to be able to make the

penis erect and have penetrative sex?

As with the metoidioplasty, your surgeon should be able to provide you with

images, and may be able to refer you to other patients whom he or she has

treated. You will need to understand the risks associated with this complex

surgery, so that you are able to make joint decisions with the surgeon, and give

properly informed consent to each of the procedures.

N.b. The following text should only be regarded as an introduction to the possible

procedures that may be involved in phalloplasty. Techniques depend not only on

your choices, but also on the practice and experience of your surgeon, and your

own particular anatomy. It is not within the scope of this booklet to cover all these

possibilities.

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How do I choose the donor site?

One of the first decisions to be made is about the donor site – the area of your

body that will provide the tissue from which the phallus is to be made. The site will

depend, partly, on your surgeon’s preference and his or her view of what can be

achieved in your particular case. Of course, it will also depend on what outcome

you are hoping for, and where you are prepared to have the scar caused by the

removal of a large area of skin.

Donor flaps may be described as ‘pedicle or ‘free’; a pedicle flap is initially only

freed at one end, whilst the other end remains attached and retains some of its

original blood supply; the ‘free’ flap has to be detached completely and moved to

the new site, and blood vessels and nerves have to be re-attached to nerves and

blood vessels at the new site.

Forearm flap

The most common donor site is the radial forearm flap although, in a very few

cases, the arm may be too thin to provide enough skin. This is a ‘free’ flap

although some of the refinements to the phallus may be done before the flap is

detached from the arm. If you are right handed, the flap will be taken from the left

forearm, and vice versa. For good results, hair removal from the site should be

complete before surgery. It may take some months, possibly as long as a year to

achieve complete removal of hair from your lower arm. It can be done with light

based procedures such as laser or intense pulse light, or by electrolysis. The

method of hair removal will depend on your skin and hair type. You should discuss

this with the professional providing this service.

Blood vessels are also taken from the forearm and joined up with those in the

pelvis, to ensure that the penis has an adequate blood supply. It is usual to take

one artery (arteries carry oxygenated blood to the tissues), and two or three

veins (veins carry the de-oxygenated blood back towards the heart).

Nerves are also taken from the arm and are joined, at the base of the penis, to

nerves in the abdomen. Unfortunately, the nerves do not function immediately.

It takes many months – maybe up to a year – before the nerves regain function.

It is, therefore, important to understand that during this time the penis will not

have sensation. If you have this surgery, you will need to take care not to

damage your penis while there is no feeling in it.

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


The advantage of the forearm flap:

the advantage of using the forearm flap is that the results usually look good.

Compared with other methods, the urethra that is created at the same time,

also using skin from the forearm, is less problematic. There is one join at the

base of the penis where the new urethra is hooked up with the existing urethra

(that has been slightly extended with mucosal tissue). It is less prone to

narrowing and blockage than a urethra that has several joins. Re-growth of hair

may cause problems with this method, if hair follicles are still active.

The disadvantages:

One disadvantage of the forearm flap is the visibility of the scar at the donor site

that may create some self consciousness when wearing short sleeved

garments.

Also, the donor site will need a

secondary skin graft to help the area

heal. This may be full-skin thickness or,

more usually, a very thin (split thickness)

graft. It may be taken from the thigh or

buttocks. The arm will be covered with a

pressure garment for anything from six

months to a year. You will probably need

post-operative care for the donor site

from your local practice nurse.

penile flap

urethral flap

Recovery time following surgery is longer when using this donor site than it is

when the abdominal flap is used (see table below).

Abdominal flap

The next most common donor site is the skin from the lower abdomen. Again some

hair removal is likely to be necessary before surgery is carried out. It should be

noted that using the skin in the area usually covered by pubic hair means that the

skin drawn down to cover the donor site will have little or no pubic hair.

If you are a lean individual you may need to put on a pound or two in weight in

order to create some subcutaneous fat so that the phallus is bulky enough.

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As this is a pedicle flap, arteries, veins and nerves will be in tact, but sensation

may still be delayed for a while until the nerves have recovered from the surgery.

Abdominal flap

donor site

The advantages:

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

first stage

phalloplasty

a much less visible scar than with the forearm flap, although it will

create a long scar across the abdomen;

no secondary graft is required on the donor site.

The disadvantages:

if a urethra is required, it may by provided at a follow-up stage; the tissue used

is usually a free-flap from the forearm which causes only a relatively small

amount of scarring or, if you really do not want any scarring at all on the

forearm, the urethra may be constructed in sections from other areas such as

the mucous membrane lining the vagina or mouth. If sufficient tissue is not

available the urethra may not extend to the tip of the penis and will end

somewhere along the underside of the penis in the same manner as the

condition called hypospadias. Also the joins between the sections can all give

rise to fistulae formation (small gaps in the joins) and therefore leaks and

possibly infections.

Alternative donor sites for phalloplasty preferred by some surgeons:

skin from the front-side of the thigh (antero-lateral thigh flap – ALT). This site is

being used increasingly. It may be used as a pedicle or a free flap. It is

successful, the donor site is less conspicuous and the blood supply is good; it

may be preferred where urethroplasty is not required. Urethroplasty can be

undertaken with the ALT flap, by using the forearm as the donor site for the

urethral tube only. Compared with the technique that uses the forearm as the

donor site for the outer tube as well, this approach obviously causes a much

smaller area of scarring that is on the inside of the arm and is much less

conspicuous; or

a groin flap; or


tissue from a large back muscle and the skin covering it (Latissimus Dorsi flap);

or

from the buttocks.

What outcome am I looking for?

All phalloplasty options should provide you with a sensate penis, that is, one with

ordinary skin sensation. However, it may not have the sexual sensation of a penis,

but this depends on the surgical techniques used by your surgeon. As mentioned

above, sensation will, in any case, be delayed for a few months.

You may choose to have a basic penis without a urethral extension or erectile

implants.

The advantages are:

your surgery is more straightforward, it will take less time; and

you will avoid the complications that are associated with lengthening the

urethra (fistulae or stenosis).

The disadvantages are:

you will find penetrative sex difficult or impossible; and

will not be able to urinate through the penis and, therefore, will not be able to

urinate standing up.

You may choose a penis with a urethra

Approximately 73% of those undergoing phalloplasty in the UK have chosen to

have the urethra extended.

The advantage:

The benefit is that you will be able to urinate standing up and will, therefore,

be able to use a urinal; apart from the practical advantage, you may find that

this is psychologically beneficial.

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The disadvantage:

You risk complications, the most frequent of which, is that the urethra

becomes narrow and may become blocked (stenosis). In order to try to

prevent this happening, you have to keep a catheter running through the

urethra, for a short time after surgery. You may also have a second

’suprapubic’ catheter in place; this emerges just above the pubic bone and

carries urine directly from the bladder. This will be clamped after about one

week and, gradually urine will emerge from the urethral catheter. Once this is

established the suprapubic catheter can be removed. Occasionally, leaks

develop (fistulae) where joints have been made to add sections of tissue to

lengthen the urethra. Even when it is all healed and you are able to urinate

standing up, you may find it difficult to direct your urine, and you may

experience spraying. If you have slight dribbling following urinating, this can

usually be overcome by squeezing the penis from its base, to make sure that

all urine is pushed out.

You may choose to have a penis that can be made erect

In the UK, approximately 31% of those undergoing phalloplasty have elected to

have erectile implants.

The advantages:

Erectile implants, of the same kind as used in genetic men with erectile

problems can be inserted into the newly created phallus. They are very

effective and facilitate penetrative intercourse. This is a psychological benefit

and also adds an important dimension to your sexual function.

The disadvantages:

This will always involve further surgery and, therefore more time off work, and

more risk of complications. Sexual sensation may be slightly ‘dulled’ if the

clitoris or micro-penis is ‘buried’.

How do erectile implants work?

There are two types of erectile implants:

30

Semi-rigid rods; one or two are placed inside the shaft of the phallus. When

an erection is desired the phallus is bent upwards. The construction of the

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


ods is such that the penis is able to retain an erect profile until such time as

the procedure is reversed by bending the phallus down again. 12

This end lies

towards the tip of the

phallus.

The central section

has articulating

plastic segments so

that the phallus may

be bent down as

shown on the right

This end

of the

device is

placed

near the

root of the

phallus

The disadvantage of this type of prosthesis is that the length and width of the

phallus does not alter. The length of the erectile device is cut to correspond to the

length of the phallus and is therefore of a fixed length. Also, when bent down it

remains relatively rigid and harder to conceal. This is a less popular kind of

prosthesis.

12 Courtesy of American Medical Systems, Inc. Minnetonka, Minnesota (Dura II ®)

www.americanmedicalsystems.com

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alternatively, a more complex device may be implanted, comprising a

reservoir of fluid, a pump and one or two expandable rods. 13 The pump

device is placed in the scrotum and the rods are placed in the phallus. The

reservoir may be placed either in the lower abdomen (involving an extra stage

of surgery) or in the scrotum. Your surgeon will discuss with you which is

suitable in your case.

reservoir

expandable

rod

pump

When an erection is desired, the pump is squeezed to transfer some

of the fluid from the reservoir to the expandable rods. They thus

become more rigid, slightly larger in length and circumference. This

mimics the natural erection more accurately. When the erection is no

longer desired, the valve is released and the fluid drains back into the

reservoir, the phallus returning to its original size.

expandable

rod

reservoir

and pump

If you are planning to have erectile prostheses, you need to be aware that

although these devices make the penis rigid, which allows penetration, this

rigidity is confined to the centre of the phallus. The feel of the skin on the

outside of the penis is still soft because the skin from the donor site has no

capacity to become hard.

Implant infection is a possible complication of this procedure. Infections may not

become apparent for many months after the surgery. Mechanical failure is

possible, but very unlikely; one report indicates a 5% re-operation rate.

Revision rates following these implants are higher in trans men than in other

men, up to 25%.The life-span of the prosthesis is between five and ten years

so, depending on your age, you will need to consider the possibility of further

surgeries. 14 , 15

13 Courtesy of American Medical Systems, Inc. Minnetonka, Minnesota All rights reserved

www.americanmedicalsystems.com (AMS Ambicor®; AMS 700®)

14 Santucci, RA, Knopik, C, Chang, Y-J (2007) Penile prosthesis implantation, Emedicine at WebMD

Available at www.emedicine.com/med/topic3047.htm N.b. This article refers to surgeries in nontrans

men.

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Creating the glans

Penis with sculpted glans and

testicular prostheses.

Penis made erect with penile

prosthesis. The glans-shaping

in this example is not entirely

satisfactory but variation must

be expected.

TR TR

Either at the time of the initial operation, or when the first stage of creating the

phallus has healed, the head of the penis (glans) can be sculpted to give a realistic

looking appearance. The coronal sulcus (slight groove where the shaft of the penis

meets the glans) is fashioned to create the ‘pinched in’ appearance. Colour can be

added with medical tattooing of the glans as the male phallus is usually a different

colour to the shaft. This may be done in the months following surgery when the

penis is still without skin sensation. The appearance of the glans can be improved

in this way, whether or not you have other refinements such as an extended

urethra or erectile implants. Approximately 50% of those undergoing phalloplasty in

the UK have chosen to have the glans shaped.

15 In the UK the more expensive three-part prosthesis (£5,200) is used as it simulates more closely

the rigidity and flaccidity of a natural penis. It requires an extra stage of surgery, but is covered

by warranty. The two-part prosthesis is used in Belgium; it can be implanted in one operation

and is less expensive (£2,500). Prices may change over time.

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shaft of

phallus

sulcus

glans

catheter

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

This image shows the appearance

of the glans immediately postoperatively,

where the glans has

been created while the forearm

flap was still attached to the arm

and still had its own blood supply.

The distinctive shape of the glans

of the penis is created using a

small skin flap and graft from the

arm.


The pelvic floor showing diagrammatic representation of scrotoplasty

A refinement of the techniques outlined in the metoidioplasty section for creating a

scrotum, is undertaken by some surgical teams 16 , as shown below.

Labia minora

around

entrance to

vagina

Labia majora

X X

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TR

The lower ends of the labia

majora are shown turned up and

stitched into place to create a

double pouch that will later house

the testicular prostheses. The

clitoris is moved up and buried

under the shaft of the penis. In

this picture a catheter is in place

to drain the bladder.

The clitoral hood (the tissue that

covers the top of the clitoris) can

be incorporated into the scrotum

to enhance erogenous sensation.

A horizontal incision is

made just above the

pubic bone to access

blood vessels and the

new urethra from the

bladder. The area

below this incision and

above the Xs remains

in place.

Lower sections of the

labia majora are

surgically released.

16 Technique reproduced courtesy of Professor Stan Monstrey, University Hospital, Ghent, Belgium.

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36

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catheter

emerging from

the urethra

glans penis

shaft of penis

clitoris

testes with

prostheses

TR

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

The scrotal sac shown here has

been created in the way described

above. It does not yet have

testicular implants. This technique

is found to give a more masculine

appearance especially once the

implants are in place.

Penis seen from the underside, with

sculpted glans. The catheter is still in place

to ensure that the newly created urethra

remains open.

Testicular prostheses are in place and,

between the testes, the clitoris is just

visible, so it has not been ‘buried’, and

metoidioplasty had not taken place in this

individual. Those trans men who have not

undergone metoidioplasty, or who have

not had one of the clitoral nerves attached

to a nerve grafted in from the forearm, may

prefer to have the clitoris available for

direct sexual stimulation.


Sequence and approximate timing of surgical procedures

1. Radial forearm flap phalloplasty (combined with chest reconstruction) (UK)

Operation

Radial forearm flap

Operation time Hospital stay Recovery time

hysterectomy

Chest

six to eight hours seven days six weeks

reconstruction 17,18

Hook-up

urethroplasty

Vaginectomy

Glans, testes and

reservoir

Penile implant

two hours

one hour

two hours

one to three days

23 hours

23 hours

two weeks

one week

one week

Although the immediate recovery time for phalloplasty is given as six weeks, many

people continue to feel rather fragile for a lot longer. You may need to consider

more time off work, depending on the nature of your job. A desk job will clearly be

easier than, say, a gardening job. As mentioned earlier, your recovery time will be

partly dependent on your health before surgery.

Some surgical teams outside the UK prefer to do most of the surgical procedures

in two operations. In Belgium, for instance, vaginectomy and pelvic floor

reconstruction are done in the same procedure as the phalloplasty (using forearm

flap), urethroplasty, scrotoplasty and glans sculpting. There are obvious

advantages in terms of time off work, however, the operation itself takes eight to

ten hours, slightly longer than the UK where the procedures may be a little more

spread out. In both Belgium and the UK, erectile prostheses are fitted about 12

17 The issue of chest reconstruction has not been dealt with in this booklet, but surgeons may do

this surgery together with some stages of phalloplasty (See Chest reconstruction for female to male

trans people (2002) FtM London, published in conjunction with consultant surgeon Mr Dai Davies. This

booklet gives comprehensive advice on all aspects of chest surgery. For further information contact

info@ftmlondon.org.uk or contact Mr Davies at enquiries@plasticsurgerypart.org.uk or via the website

at www.cosmeticsurgeryuk.com

18 Some trans men, especially those who are heavy-breasted may have this surgery before

meeting the eligibility criteria for genital surgery. (See Feldman, JL, Goldberg, JM.

(2006).Transgender primary medical care, International Journal of Transgenderism, 9(3/4):3–34)

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

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months later when sensation is established in the penis. Some Primary Care

Trusts may fund surgery in Belgium as well as in the UK.

2 Radial forearm flap phalloplasty (combined with chest reconstruction)(Belgium)

Operation

Laparoscopic

hysterectomy

Operation time Hospital stay Recovery time

Salpingooophorectomy

Chest

four hours three to five days three to four weeks

reconstruction 19

Forearm flap

Urethroplasty

Vaginectomy

Scrotoplasty

Glans sculpting

Penile implant

eight to ten hours

two hours

3 Abdominal flap without urethroplasty (UK).

17 – 18 days

two days

ten to 12 weeks

one week

Operation Operating time Hospital Stay Recovery time

Abdominal

Phalloplasty

Glans sculpting,

Testis,

Reservoir

Penile implant

three to four hours

two hours

two hours

three to seven days

one to two days

two to three days

three weeks

one week

two weeks

As with other surgeries, the time given for recovery – three weeks – is a minimum,

and most people will take longer to feel really well and to be strong enough to

return to work. Occasionally abdominal phalloplasty may be undertaken in

19

Chest reconstruction may already have taken place in which case these times will probably be

shorter.

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conjunction with abdominal hysterectomy, in which case the timings mentioned

here will be considerably increased.

Risks associated with surgery:

bleeding;

pulmonary embolus;

wound breakdown;

anaesthetic problems;

infection;

deep venous thrombosis (DVT).

Possible complications of phalloplasty:

loss of phallus (when arterial blood supply fails the tissue dies. This is rare);

loss of forearm skin graft (necessitating a further graft);

venous ischaemia (when the veins carrying blood back towards the heart

collapse causing back-up blockage in the arterial system. Small areas of

tissue can die or, in very rare cases, the phallus can be lost);

urethral stricture (closing of the urethra. This is rare);

urethral fistula (leakage through joints; about 30% of people had this problem.

Some self-heal; others will need further surgical correction; and

in the UK about 15% of people need further surgery to correct one of these

problems. A minority of these will have more than one surgical correction.

THE RISK OF COMPLICATIONS INCLUDING LOSS OF PART, OR ALL,

OF THE PHALLUS, IS SIGNIFICANTLY GREATER IF YOU SMOKE.

Some clinicians will not operate unless service users have stopped

smoking for at least a year.

98% of those having phalloplasty in the UK judged their appearance as good or

excellent. Among those whose surgery was long enough ago that a return of

sensation would be expected, 70% reported complete skin sensation, and 14%

reported partial sensation. Two people lost the phallus (n=111).

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39


Among those who had urethroplasty, 98% were able to urinate standing up.

The final appearance of the forearm donor site was reported as excellent in

approximately 72% of people; and moderate to good in the remaining 27%. Skin

sensation was complete in nearly 90%, and less than 4% experienced some loss

of movement.

In Belgium the results are similar, in that most problems arose with urethral

extensions: 24% had a fistula; 19% had stenosis. Most of the fistulae healed

spontaneously and more than half the stenoses were corrected under local

anaesthetic but sometimes secondary surgical procedures were necessary. 16%

had vascular (blood supply) problems, most of which required further surgical

intervention, however, only 8% lost small amounts of skin; two people lost the

phallus altogether (n=250). 20 Otherwise all were satisfied with their appearance.

It is worth thinking about the fact that this kind of surgery has a relatively high rate

of further surgical interventions to correct problems, so you should mentally

prepare yourself for this.

20 Monstrey, S, Ceulemans, P, Hoebeke, P (2007) Surgery: female to male patient. In Principles of

Transgender Medicine and Surgery, Randi Ettner, Stan Monstrey, A. Evan Eyler (eds.) pages

135–168.

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What about my sex life now?

As mentioned above, your sexual sensation is more limited in range after surgery

to remove the uterus and close the vagina. Contractions during orgasm that would

usually be felt in the vagina and the uterus will obviously be lost once these organs

are removed. Areas that are especially sensitive to stimulation are not only the

clitoris but, in many women, the ‘G spot’ 21 which is on the front wall of the vagina, a

little way above its opening on the pelvic floor. The cervix is also particularly

sensitive in some women and may be stimulated by the penis during vaginal

intercourse. Most trans men do not find the loss of some sexual sensation

problematic because testosterone makes the experience more intense.

erogenous hotspots:

cervix

G spot

clitoris

areas in which the

orgasm may be

experienced are

shown in red

If you are planning to have a phalloplasty, you may prefer to leave the clitoris

uncovered between the scrotal sacs where it is accessible for direct stimulation

(see picture on page 33).

Otherwise the clitoris may be buried under the root of the phallus. If you have had

a metoidioplasty previously, the micro-penis will be surrounded by the skin of the

phallus. These two techniques may cause some loss of immediate sexual

sensation, but it will still be possible to stimulate the clitoris or micro-penis through

the phallus, and to achieve orgasm.

21 Gräfenberg Spot, the G-Spot was named after the gynaecologist Ernst Gräfenberg, who first

described it in 1944. It is regarded by some as the equivalent of the male prostate gland. It appears

that not everyone has a G-spot.

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41


Diagram to show the areas of sexual sensation where phalloplasty and

hysterectomy with vaginal colpoclesis is performed

The penis may cover the clitoris or be wrapped around

the micro-penis where metoidioplasty has taken place.

The underlying micro-penis, or the technique used in

Belgium of grafting a nerve from the forearm onto one

of the nerves supplying the clitoris, causes sexual

sensation to be carried further along the penis.

The phallus itself will have skin sensation, but little erogenous sensation. Those

who have undergone the Belgian technique of extending the clitoral nerve report

some sexual sensation in the phallus, although not along its entire length. The

inclusion of the clitoral hood in the scrotum is also believed to enhance erogenous

sensation.

If you have had phalloplasty with erectile implants, you will be able to achieve

penetration. The phallus itself is not capable of becoming engorged and therefore,

is not rigid on the outside. It is only rigid at its core. Although some report pain on

intercourse, most of those who have had the erectile implant say that they are

pleased with the improvement in their sexual function.

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14 Sexual behaviours and keeping safe from sexually transmitted infections

(STIs) 22,23,24,25

Behaviours

Sexual behaviours among trans men may be extremely varied depending upon:

their sexual orientation, that is, whether they are attracted to men or to women

or both, neither; and/or

the type of anatomical changes that they have undergone as part of their

treatment.

Sexual orientation

Although sexual orientation usually remains the same after transition as it was

before, this is not always the case. For example, a trans man who, before

transition, has female sexual partners may, following transition:

remain attracted to women and be comfortable in a straight relationship;

OR

may be more attracted to men and prefer a gay relationship.

The reverse is also possible, that is, where a trans man who, before transition, is in

a heterosexual relationship with a straight man may, following transition,

still prefer to be in a relationship with a man;

OR

may be attracted to women and want a straight relationship.

For those who remain in the same relationship, sexual behaviour will almost

certainly need to be adapted. For instance, if your partner is lesbian, she may find

it extremely difficult to countenance being in a straight relationship with a (trans)

man. So there are likely to be emotional issues and perhaps even identity crises for

partners, as well as physical adaptations to the anatomical changes.

Where trans people are in sexual relationships with other trans people, the

possibilities are more numerous and complex.

22 Health Protection Agency (2007) prevalence available at www.avert.org/stdstatisticuk.htm

23 NHS Direct available at www.nhsdirect.nhs.uk/articles/article.aspx?articleID=436

24 NHS Sexual Health Information for Women who have Sex with Women (2006).

25 Dr Richard Curtis: advice to service users

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Changed sex anatomy

Anatomically, a trans man may or may not have: a vagina, a micro-penis, a penis

with erectile capacity. Having a penis with erectile capacity means that you are less

likely to have a vagina, however such a combination is not impossible

All these possibilities will impact on sexual behaviours and, consequently, the

degree of risk of STIs to which a trans man may be exposed. You will be at least

risk if you are having non-penetrative sex (most likely with a woman). However,

infections can be passed between partners through rubbing vulvas together or

hand contact. You will be at most risk if you are having anal penetrative sex (most

likely with a man); and there are various shades of risk in between. Penetration

with sex toys where these are shared can also cause infections to be passed

between partners.

The behaviours that put you at most risk are:

Unprotected penetrative sex, especially anal sex; and

Multiple sexual partners

Hygiene is important although, on its own, it will not prevent infections being

passed on. You should have clean hands and clean genitals, sex toys should be

washed every time they are used, and this includes when they are used for more

than one orifice on the same occasion. Avoid oral sex if you have any cuts or sores

on the mouth; use latex condoms for penile penetration. Wear latex gloves and use

plenty of water-based lubricant for vaginal and anal fisting, or when using dildos

(water-based products do not damage rubber).

Douching should not be necessary as the vagina is self-cleansing. Soreness

around the entrance to the vagina can occur when using perfumed soaps and

bubble baths. Specific conditions such as Bacterial Vaginosis and Thrush can also

be caused in this way, and it is also possible that they can be passed on through

sexual touching or using sex toys. However, they are not necessarily related to

sexual activity. The symptoms of Bacterial Vaginosis are a fishy smelling thin green

discharge; this is treatable with antibiotics. The symptoms of Thrush include:

itching; pain on vaginal penetration; burning sensation when passing urine and

thick white discharge. Medicated creams, pessaries and tablets can be bought at

pharmacies but you should see your doctor if these symptoms persist.

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STIs

Sexually transmitted diseases are seldom trivial; all of them can have serious

consequences and several are not curable. They can blight the lives of the

individuals that have them, and also the lives of those around them. If you have

any reason to believe that you might have contracted an STI, you should seek

medical help from your GP or a Sexual Health Clinic. Many people find this

embarrassing, but remember, the staff in specialist clinics are professional people

who deal with these situations all the time and they are not judgemental.

Ideally, you should be tested for STIs before having surgery so that you can

receive appropriate treatment. In particular, it is good practice for HIV (Human

Immunodeficiency Virus) tests to be undertaken, and some surgical teams insist on

it. If you are found to be HIV positive, this is not a reason for withholding your

surgical treatment.

STIs are quite common and their prevalence is still rising. The prevalence of all of

the following conditions has increased by 63% over the last 10 years. The total

number of STIs in 2006 was 621,300 of which 376,508 were new infections.

In addition to HIV, they include:

syphilis,

gonorrhoea,

herpes,

chlamydia,

hepatitis A, B, C,

genital warts, and

trichomonas vaginalis

HIV

HIV infection is a lifelong condition; it can be treated with antiretroviral drugs, but

not cured. Treatments may include a mixture of medications that combine to

provide ‘highly active antiretroviral therapy’ (HAART). In the longer term health may

decline progressively. The virus may be passed on through body fluids from the

vagina or the penis, from blood and it can enter the bloodstream through breaks in

the skin or membranes lining the vagina and rectum and from shared needles.

There are different strains of HIV and having one strain, does not protect against

catching another.

There are approximately 49,500 HIV positive people in the UK; it is estimated that

up to 40% them are unaware of their condition since it can remain symptomless for

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many years. 26,27 Since people do not know that they have the condition they are

more likely to infect others. New infections fell from 7,900 in 2005 to

approximately 7,800 in 2006. New infections among heterosexual people have

been falling since 2003. The infection rate among gay men has risen by 20% over

the last five years and is continuing to rise. Studies indicate that 30% of those who

know they are HIV positive continue to have unprotected sex. 28

Many people experience flu-like symptoms in the first couple of months; these may

include:

a high temperature and fever;

a sore throat;

fatigue;

a skin rash;

muscle aches and pains;

headaches;

nausea and vomiting; and

diarrhoea.

If the virus is allowed to spread, your immune system will eventually become

weakened and you will develop AIDS (auto, or acquired, immune deficiency

syndrome) which will eventually be fatal because your resistance to cancers and

infections will be significantly lowered making you vulnerable to other STIs and a

range of infections, including:

infections of the mouth;

recurring mouth ulcers;

herpes or shingles infections;

unusual types of pneumonia;

tuberculosis (TB);

infections of the brain and eyes;

hepatitis C:

unusual skin problems: and

infections of the gastrointestinal tract.

26 Royal College of Obstetricians and Gynaecologists (2004) Management of HIV in pregnancy

39:1. Available at www.rcog.org.uk/resources/Public/pdf/RCOG_Guideline_39_low.pdf

27 Medical Research Council (2008) available at:

www.mrc.ac.uk/OurResearch/Impact/Infections/HIVbehaviour/index.htm

28 See Aidsmap at www.aidsmap.com/en/news/F4D5934E-1662-4796-A35D-9BB0C32D2EFA.asp

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Most people with an advanced HIV infection will also experience severe body

wasting and weight loss.

If you have good reason to believe that you have just put yourself at risk through

intimate contact with someone who is HIV positive, you should seek post exposure

prophylaxis (PEP) from a sexual health clinic or an Accident and Emergency

department of a local hospital. PEP is a course of anti-HIV drugs which may be

successful in preventing HIV infection after HIV has entered the body. 29

If you are HIV positive and you are pregnant, you will need to take special

precautions to guard against your baby becoming HIV positive. 30 You should have

anti-retroviral treatment; you should plan to have a caesarian delivery and you

should not breast-feed.

Syphilis

There were 301 cases of syphilis in 1997, rising to 3,702 in 2006 – an increase of

1,607%.The disease is commonest in gay men. It can be treated with antibiotics.

There may be mild symptoms or none at all. The symptoms of first-stage syphilis

may take up to three months to become evident. They include:

one or more sores (ulcers) on the penis, vulva, vagina, cervix, mouth or

anus, that weep pus; they may last for around six weeks; and /or

small lumps due to swollen glands in the groin.

The symptoms of second stage syphilis usually appear several weeks after any

ulcers have gone. The following symptoms come and go over many years. They

include:

a non-itchy rash of dark patches, often on the palms and soles as well as

other areas;

feeling generally unwell, fever, extreme tiredness and malaise, headaches;

wart-like growths on the genitals;

white patches inside the mouth;

patchy hair loss (alopecia); and

more rarely, major body organs such as the liver, kidneys and brain begin

to be affected.

29

Terrence Higgins Trust (2007) HIV? AIDS? Fifth Edition. E-mail: info@tht.org.uk;

Tel: 020 7812 1600

30

Royal College of Obstetrician and Gynaecologists (2005) HIV in pregnancy: information for you.

Available at www.rcog.org.uk/resources/public/pdf/hivinpregnancy.pdf

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The first and second stages of syphilis are highly infectious.

The symptoms of the second stage may disappear and the infection can lie

dormant for many years (latent syphilis) but, in time, third stage syphilis develops

which can seriously damage major body systems and organs and will ultimately be

fatal.

Gonorrhoea

Gonorrhoea rose from 13,063 in 1996, to a peak in 2003 of 25,000 cases.

However, largely because numbers of cases have fallen in the heterosexual

community, overall numbers have fallen back to 19,007. The present figures are

therefore up by 46% on the 1996 figures. Cases of gonorrhoea among gay men

continue to rise so if you are having sex with gay men, you are at greater risk of

contracting gonorrhoea than if you are having sex with straight men or with women.

But there’s no such thing as no risk. Gonorrhoea can be treated with antibiotics.

The following applies to trans men who have not had vaginectomy and who are

having, or have had, vaginal penetrative sex with a man.

About 50% (of women) do not experience symptoms and therefore the infection

may go untreated for some time. Untreated gonorrhoea can cause serious health

problems.

The 50% who have symptoms may experience the following:

A strong, unpleasant smelling thick discharge from the vagina, that may

appear green or yellow in colour,

pain or tenderness in the lower abdominal area, including a burning

sensation when urinating,

frequent need to urinate

irritation or discharge from the anus, and

bleeding between periods or heavier periods (this symptom would not occur

with a trans man who was high enough testosterone dosage to suppress

periods).

Herpes simplex virus

The number of cases of genital herpes has risen from 16,615 in 1996 to 21, 698 in

2006 – an increase of 31%. In the last few years there has been a rapid rise in the

numbers of teenage girls who have genital herpes.

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Many people who have genital herpes do not experience any symptoms, but if you

do, the onset is usually between 2-7 days after exposure to the virus (usually by

sexual contact). However, it is important to note that symptoms occasionally do not

appear until months, or sometimes years, after being exposed to the virus.

The first occurrence of genital herpes may cause a range of symptoms including:

mild fever,

aches and pains,

swollen lymph glands (at the top of your legs), and

feeling generally unwell.

These symptoms may last for up to 21 days.

You may also have an itching or burning sensation in your genital area. Painful red

spots may appear around your genitals that gradually turn into fluid-filled blisters.

These blisters will then burst, leaving painful ulcers. However, the ulcers will

eventually dry out and heal, after about 10 -14 days, and should not scar. These

symptoms can vary from person to person. For example, you may not experience

the blisters, but only have ulcers that appear to be small cuts or cracks in your skin.

The symptoms of genital herpes usually affect the vulva (entrance to the vagina)

and sometimes the cervix but any part of the genitals and the surrounding area

may be affected. You may experience vaginal discharge. If you are having

penetrative sex with a man, his symptoms are likely to affect the end and shaft of

the penis, the foreskin, and sometimes the testicles. It is also possible, though less

common, to have sores on the buttocks, anus and top of the thighs.

Urinating may be very painful.

Once the initial infection has subsided, the symptoms will disappear, but the virus

will still be present and can be reactivated.

When this happens the symptoms are usually milder and last for about 3-5 days. If

the virus is reactivated, it will cause symptoms of itching, or tingling, sensation

around your genitals, lasting for between 12- 24 hours.

If recurrences are frequent and disabling they can be treated with anti-viral drugs

that shorten the length of the episode. Herpes is incurable and recurs throughout

life.

Chlamydia

Chlamydia accounts for 30% of all new cases of STIs. In 1996 there were 42,668

cases. In 2006 there were 113,585 cases – a rise of 166%. This condition may

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emain symptomless but can lead to infertility. It can be treated successfully with

antibiotics.

In trans men having non-penetrative sex with a woman, (rubbing vulvas together)

or having penetrative sex with a man, or with a woman (perhaps using sex toys) in

the vagina and/or the anus, genital chlamydia can occur and may cause:

pain when passing urine (cystitis);

a change in their vaginal discharge; and

mild lower abdominal pain.

If you have any of these symptoms, or you believe you may have chlamydia you

can ask to be tested by your doctor or your local pharmacist, or you may be able to

do the test at home. Those over the age of 16 who have tested positive but who

are still symptomless, will be able to buy the necessary antibiotic over the counter,

without a prescription, from 2008. This will be available to partners as well.

If left untreated, the chlamydia infection may lead to the following symptoms:

pelvic pain,

pain during sexual intercourse, or occasionally,

bleeding between periods.

The infection can also spread to the uterus, and cause pelvic inflammatory disease

(PID). If you wish to become pregnant at some future time, you should be aware

that PID causes infertility and risk of ectopic pregnancy in those still at risk.

Hepatitis

Hepatitis A and B affect the liver and can cause jaundice. Hepatitis can be

transmitted in several ways, one of which is by sexual contact.

Hepatitis A can be transmitted through sex involving mouth to anus contact.

Hepatitis B can be transmitted in body fluids and the risk is, therefore, higher

during menstruation. It is strongly recommended that vaccination against hepatitis

A and B is undertaken by those having anal sex. This involves three injections over

a period of a few months; this provides life-long protection. This treatment can be

provided by a genito-urinary medicine (GUM) clinic.

Hepatitis C can be passed on through sexual contact and, as mentioned above,

you are at increased risk of catching it if you are HIV positive. Although it cannot be

passed on by ordinary social contact, it can be transmitted through, for instance,

sharing toothbrushes. You are at high risk if injecting drugs with shared needles.

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Hepatitis C can cause cirrhosis of the liver. The symptoms are very like those of

chronic fatigue syndrome, but may be slight so people do not always know that

they have Hepatitis C. The onset of symptoms may be delayed as long as 20

years. So unless you have been tested for it, you may not be aware until you

develop liver failure many years down the line.

Symptoms include:

weight loss

loss of appetite

joint pains

nausea

flu-like symptoms (fever, headaches, sweats)

anxiety

difficulty concentrating

alcohol intolerance and pain in the liver area

Hepatitis C is treated with a combination of pegylated interferon alpha and ribavirin.

Genital warts

Genital warts are fleshy growths around the vulval and anal area. They are caused

by the human papilloma virus (HPV). There are many kinds of HPV, a few of which

are associated with pre-malignant changes and cervical cancers, so this would be

relevant to those trans men who are having vaginal sex with a man. Smear tests

are important for those who still have a cervix. HPV can penetrate mucosal and

skin surface through minor abrasions. Genital warts can be treated by ‘freezing’ or

with medicated cream.

Trichomonas Vaginalis

Trichomonas Vaginalis is caused by a tiny parasite found in the vagina and

urethra.

It is passed on through:

vaginal sex

sharing sex toys

Many infected people show no symptoms, but symptoms can appear between

three and 21 days after infection.

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Symptoms include:

increased discharge from the vagina, that may change in colour and have a

musty or fishy smell

itching, soreness and inflammation in and around the vagina

pain when passing urine or having sex

tenderness in the lower abdomen

Treatment involves a single dose or a course of antibiotics.

How can I protect myself against all STIs?

Always use condoms for penetrative sex –

52

You or your partner should use a condom every time you have sex whether,

vaginal, anal or oral;

Practise putting one on before you need it for real;

It must go on an erect penis, before penetration;

Use known brands that are kite marked;

Check the expiry date;

Only use once;

Do not bite the pack to open it;

Do not stretch the condom before putting it on;

Get the right size for you: narrow ones called ‘TRIM’ are made by Pasante

(pasante.com); regular size is approximately six inches long by four inches

girth and large is eight inches long by six inches girth;

If you are having penetrative sex with a woman and you have had

metoidioplasty, condoms will not fit your micro-penis; you may need to ask

your partner to wear a female condom;

If you are allergic to latex, use polyurethane (Durex, Avanti).

Standard condoms are now thought to be robust enough for anal sex.

Use lubrication (water-based) – it helps to prevent damage to mucous

membranes

Remember penetration with anything, hands, fingers, sex toys as well as

penises can transfer infection

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Ordinary hygiene helps to limit risk of less serious infections

Remember, more partners means more risk – what do you know about the

person with whom you are having sex? With each new partner you are

putting yourself at risk of being infected by anything passed on by any of the

people with whom this person has had intimate contact.

Get medical help quickly if you think you may be infected.

If you are having vaginal penetrative sex, you should have smear tests done in the

same way as for women.

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Information and support

a:gender

Tel: 020 7035 4253

Email: agender@homeoffice.gsi.gov.uk

Website: www.csag.org.uk

Support for staff in government departments/agencies who have changed,

or who need to change permanently their perceived gender or who identify

as intersex.

Depend

BM Depend, London WC1N 3XX

Email: info@depend.org.uk

Website: www.depend.org.uk

Free, confidential, non-judgemental advice, information and support to

family members, partners, spouses and friends of transsexual people.

FTM Network

BM FTM.org.UK, London WC1N 3XX

Tel: (Wed, 8-10:30pm) 0161 432 1915

Website: www.ftm.org.uk

Advice and support for female to male transsexual and transgender people,

and to families and professionals; ‘buddying’ scheme; newsletter: Boys

Own; annual national meeting.

Gendered Intelligence

Tel: 07841 291 277

Website: www.genderedintelligence.co.uk/

Company offering arts programmes, creative workshops trans awareness training,

particularly for young trans people.

Gendys network

BM GENDYS, London WC1N 3XX

Email: gendys@gender.org.uk

Website: www.gender.org.uk/gendys

Network for all who encounter gender problems personally or as family

members, lovers or friends, and for those who provide care; quarterly

journal; biennial conferences.

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


GIRES

Gender Identity Research and Education Society

Melverley, The Warren, Ashtead, Surrey KT21 2SP.

Tel:01372 801554

Email: admin@gires.org.uk;

Website: www.gires.org.uk

Promotes and communicates research; provides information and education to help

those affected by gender identity and intersex conditions. Offers range of literature,

e.g. to help families deal with ‘transition’.

Mermaids

BM Mermaids, London WC1N 3XX

Tel: 07020 935066

Email: mermaids@freeuk.com;

Website: www.mermaids.freeuk.com

Support and information for children and teenagers who are trying to cope with

gender identity issues, and for their families and carers. Please send SAE for

further information.

Press for change

BM Network, London WC1N 3XX

Tel, emergencies only: 0161 432 1915

Website: www.pfc.org.uk

Campaigns for civil rights for trans people. Provides legal help and advice

for individuals, information and training; newsletter and publications.

Please send SAE for further details.

The Beaumont society

27 Old Gloucester St, London WC1N 3XX

Tel: 01582 412220

Email:enquiries@beaumontsociety.org.uk;

Website: www.beaumontsociety.org.uk

For those who feel the desire or compulsion to express the feminine side

of their personality by dressing or living as women.

The Beaumont trust

27 Old Gloucester St, London WC1N 3XX

Telephone helpline: 07000 287878 (Tues. & Thur. 7-11pm)

Email: bmonttrust@aol.com

Website: Website: www.beaumont-trust.org.uk

Assists those troubled by gender dysphoria and involved in their care.

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

55


The Gender trust

PO Box 3192 Brighton, Sussex, BN1 3WR.

Tel (office hours): 01273 234024

Helpline (before 10pm) 07000 790347

Email: info@gendertrust.org.uk

Website: www.gendertrust.org.uk

Advice and support for transsexual and transgender people, and to partners,

families, carers and allied professionals and employers; has a membership society;

produces magazine: ‘GT News’.

The Sibyls

BM Sibyls, London WC1N 3XX

Christian Spirituality Group for transgender people.

WOBS

Women of the Beaumont Society

BM WOBS, London WC1N 3XX

Tel: 01223 441246, 01684 578281

Email: wobsmatters@aol.com;

Website: www.gender.org.uk/WOBSmatters

Operated by and for wives, partners, family and friends of those who cross-dress

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© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN


A guide to lower surgery for trans men was prepared by the Gender Identity

Research and Education Society’s team. The work was funded by the department

of Health:

Dr Richard Curtis, BSc, MB, BS, Dip BA

Dr Joyce Martin, MB, ChB, D Obst RCOG

Professor Kevan Wylie, MB, MMedSc, MD, FRCP, FRCPsych, DSM

Terry Reed, BA (Hons), MCSP, SRP, Grad Dip Phys

Bernard Reed, MA, MBA

© GIRES A GUIDE TO LOWER SURGERY FOR TRANS MEN

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